Practitioner Issue 2, 2023

EXECUTIVE COUNCIL

RUTH-ANNE RICHTER BSc (Hon), DVM, MS FAEP COUNCIL PAST PRESIDENT rrichter@brandonequine.com

ADAM CAYOT DVM adamcayot@hotmail.com

The President's Line

Dear fellow practitioners,

I hope you and yours are doing well as we transition into the heat of summer. The long days and warm weather are a great opportunity to spend time with the family and take advantage of Florida’s springs and beaches.

The FVMA/FAEP remains aware and active on legislative issues affecting veterinary medicine. As of May 05, 2023, all bills governing veterinary telemedicine have failed to pass and move forward during the 2023 Florida legislative session. We will continue to defend the interests of veterinarians and animals by ensuring Florida adheres to the federal definition of VCPR, which protects animals from the chance of misdiagnosis and delayed care. We thank all of our members, committee leaders, and Converge Government Affairs for their assistance during this 2023 legislative session.

SALLY ANNE DENOTTA DVM, PhD s.denotta@ufl.edu

COREY MILLER DVM, MS, DACT cmiller@emcocala.com

This excellent conference offers world-class continuing education and a wet lab led by the world's foremost equine musculoskeletal system anatomist, Dr. Jean-Marie Denoix. You can read more about PES on the next page!

I hope to see you at PES this fall!

Armon Blair, DVM FAEP Council President Ocala Equine Hospital abeqdoc@gmail.com

ANNE L. MORETTA VMD, MS, CVSMT, CVA maroche1@aol.com

JACQUELINE S. SHELLOW DVM, MS FVMA PRESIDENT jackie@shellow.com

If anyone is struggling with mental wellness, please do not hesitate to reach out to colleagues, friends, or the FAEP (call 800-992-3862).

Our Membership Assistance Program (MAP), which is free for all members, offers personal and professional consultation to help you be your best. More information and wellness resources can be found at fvma.org

Opinions and statements expressed in The Practitioner reflect the views of the contributors and do not represent the official policy of the Florida Association of Equine Practitioners (FAEP) or the Florida Veterinary Medical Association (FVMA), unless so stated. Placement of an advertisement does not represent the FAEP’s or FVMA’s endorsement of the product or service.

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ODSP

GET

OFF MY BACK!

Managing the Horse With Overriding Dorsal Spinous Process

Aric Adams | DVM, DACVS Equine Medical Center of Ocala

Overriding dorsal spinous processes (ODSP) can be a common source of back pain in the working horse. It seems that this has been a focus of poor performance for decades in Europe, and, more recently, it has also become a focal topic of poor performance in North America. Because it can cause issues that include training poorly, jump refusal, bucking, and resentment to saddling amongst other training issues, it has become the diagnosis of convenience in many cases. Given the difficulty in accurately diagnosing ODSP, it can be equally confusing when trying to evaluate the success of various treatments for this disorder. We will touch on the diagnosis of ODSP and then dive deeper into treatment options for these horses.

DIAGNOSIS

The radiographic diagnosis of overriding dorsal spinous processes is more straightforward than interpreting what the findings mean. These days, most equine veterinarians possess digital radiography equipment that is fully capable of taking acceptable thoracolumbar radiographs to allow for evaluation of the dorsal spinous processes. Practitioners must be cautious when interpreting the interspinous space at the periphery of the radiograph due to divergent beam angle.¹ Some very large horses may require large overhead X-ray generators more commonly seen at referral hospitals to obtain good thoracolumbar radiographs, especially when attempting to evaluate the vertebral facets and vertebral bodies. Correlating radiographic changes in the dorsal spinous processes (DSPs) with training problems in horses is much more complex. Some horses have significant changes in the dorsal spinous processes, including overriding, bone proliferation, and bone resorption. Plus, they have no detectable clinical signs associated with these changes. Other horses may have only mild changes with seemingly severe clinical signs. Obviously, ODSP is only one of many potential

Horses may exhibit jump refusal. This behavior may or may not be new. Image courtesy of Dr. Aric Adams.

problems that can cause back pain in horses. Poor saddle fit,² thoracolumbar vertebral facet osteoarthritis,³ sacroiliac osteoarthritis and pain,⁴ and multifidus and longissimus muscle injuries are other common sources of back pain that should be investigated. Identifying horses with back pain is very subjective. This becomes even more clear when attempts are made to make a grading system in which the assessment for back pain includes pain to digital pressure, poor development of epaxial muscles, warmness in the back region, swelling, resistance to lateral bending, bad attitude, and poor hind limb impulsion – which are all inherently subjective.⁵ Still, response to back palpation is probably the most commonly employed method to verify if a horse does indeed have back pain.

In the author’s experience, the horses that are being treated tend to be “fragile flowers” or more sensitive and responsive horses than the general population. These horses may also have needle aversions and be hyperresponsive to tendon and ligament palpation on distal limbs.

This makes response to back palpation particularly challenging. Blocking the interspinous spaces adjacent to the ODSPs has been advocated to help identify if it improves their back pain or their problems when being ridden⁶ as this helps when deciding if surgical intervention is more likely to improve them. However, one must also be aware that it has been shown that diagnostic infiltration of local anesthetic in normal horses does affect range of motion and dorsoventral flexion and extension⁷ which may complicate interpretation. Others also have used positive response to injections with corticosteroids adjacent to the ODSP to help verify them as the source of back pain.⁸The use of nuclear scintigraphy has been thought to be more specific for clinical ODSP than radiography alone and may aid in differentiating from sacroiliac disease or other causes of back pain.⁹ In this study, 582 horses were presented for poor performance and back pain.⁹ Only 46% of horses with radiographic ODSP and only 25% of horses with scintigraphic uptake showed signs of back pain, while 83% of horses with marked radiographic changes and moderate scintigraphic uptake showed signs of back pain.

MANAGEMENT OF HORSES WITH ODSPS

Horses with overriding dorsal spinous processes that have clinical back pain are “managed” because the various treatments that are provided are often ongoing throughout the horse’s career. Even after surgical intervention, some horses may still require additional treatments to help them to continue to perform and decrease back pain.

PHYSIOTHERAPY

Initially, rest with no riding is usually recommended for horses with ODSP. This duration of rest is dependent on the severity of their back pain and may range from weeks to several months.

After this period of rest, back-strengthening exercises are very important in the treatment of ODSPs in horses. These exercises mainly focus on improving flexibility and improving core strength.¹⁰ Carrot stretches with the head between the front legs and to either side of the front legs have been advocated to improve core strength and flexibility. Pressure can also be placed under the ventral midline to promote dorsiflexion of the spine. Longeing with a Pessoa rig is thought to increase abdominal lift, promote back strengthening, and increase separation of dorsal spinous processes. There have been a few studies that have looked at the effect of abdominal position in relation to the proximity of dorsal spinous processes, and it has been found that the interspinous space between dorsal spinous processes is dynamic and changes with flexion and extension of the spine.¹¹, ¹² As a result, exercises under tack that involve both lateral flexion and movement and ventrodorsal flexion and movement are also key in helping these horses. Proper saddle fit during rehabilitation is of the utmost importance in these horses as thoracolumbar asymmetry from muscle atrophy may predispose them to poor-fitting saddles.²

EXTRACORPOREAL SHOCK WAVE THERAPY (ESWT)

ESWT has been used successfully to decrease back pain associated with ODSPs in horses. One recent study showed that three treatments performed two weeks apart decreased perceived back pain by significantly raising the mechanical

Studies evaluating the usefulness of physiotherapy alone to treat ODSP are lacking. Additionally, there is not much in the literature to evaluate efficacy of acupuncture and chiropractic treatment. Image courtesy of Dr. Aric Adams.

nociceptive threshold in horses.¹³ Recommendations have been varied, but more recently a protocol was advocated using 1,000-2,000 pulses total with a combination of both the 35mm and 80mm probe or the recently developed wider focused generator (Xtrode) administered globally or over the clinically sensitive or radiographically abnormal regions.¹⁴ Some use this in conjunction with non-steroidal anti-inflammatories and muscle relaxants such as methocarbamol.

LOCAL INJECTIONS

The ODSP can be injected using radiographic and ultrasonographic guidance with corticosteroids (and some use Sarapin) to decrease pain and inflammation at the site. When performing interspinous injections, the author uses radiography to identify a site adjacent to the intended injection sites and

then uses ultrasound guidance to place either betamethasone or methylprednisolone extended in volume with sterile saline along the ODSP on either side and into the interspinous ligament. It is extremely difficult to place a needle directly into the interspinous ligament from the dorsal aspect and inject it into the interspinous ligament.

Mesotherapy can also be performed in the epaxial musculature to decrease generalized pain and inflammation.

PEMF (PULSATING OR PULSED ELECTROMAGNETIC FIELDS)

PEMF is widely used amongst owners and trainers for horses that have sore backs along with a variety of other problems. There is very little scientific evidence to validate its use. It is claimed that

Illustration

of different conformational changes of processi spinosi affecting the apparent width of the interspinous space as seen in radiographs A through D. Top row shows lateral radiographs for each interspinous space with a gray line indicating the level of the corresponding CT image. Bottom row shows 2D dorsal reconstructed CT images for each interspinous space. The gray lines drawn through the CT images represent how the X-ray beams would align with the interspinous space in a lateral projection. The apparent widths caused by the different angles can be seen on the graphically present image receptor above in the gray areas on the black solid line. The black solid line at the

bottom of the figure represents the origin of the X-ray beam. Image courtesy of Dr. Aric Adams.

it increases blood oxygen, activates the lymphatic system, and that acupuncture points are stimulated.¹⁸ This process reduces pain and inflammation and promotes “overall health.” The idea of PEMF is to help relieve inflammation. Pain is thought to be caused by inflammation, so the idea is if we can relieve the pain and swelling, the body can begin to recover naturally.¹⁸

SURGICAL INTERVENTION FOR ODSP

Resection of the summits of one or more dorsal spinous processes associated with ODSP was described in 1968.¹⁹ Previously, the general premise of the surgery was to either remove the dorsal spinous process or a portion of it that is associated with ODSP and provide increased space to prevent the DSP from overriding. In more recent years, transection of the interspinous ligament has been performed as an alternative²⁰ to making large incisions and the extensive soft tissue dissection required with removal of the dorsal spinous process.

RESECTION OF DSP

Subtotal ostectomy of the overriding dorsal spinous processes have been done under general anesthesia²¹ or in the standing horse.²² , ⁸ The term subtotal ostectomy is a vague description of the procedure because opinions regarding the amount of bone that needs to be removed vary greatly. Some surgeons remove the entire dorsal aspect of the dorsal spinous process that is overriding,²² while others only remove the cranial aspect.²³ The general trend has been to move toward a minimally invasive technique that is thought to maintain most of the soft tissue attachments of the supraspinous ligament and to avoid postoperative morbidity associated with long incisions on dorsal midline. In a more recent retrospective study, 102 horses with ODSP had the cranial margin of the DSP removed through small incisions using bone ronguers.⁸

INTERSPINOUS LIGAMENT DESMOTOMY (ISLD)

Transection of the interspinous ligament between ODSPs has been advocated as an effective treatment for back pain in these horses.²⁰ This is thought to relieve tension on afferent nociceptive receptors located in the ligament insertion, thus abolishing sensation of pain.²⁴ This procedure is usually performed in the standing sedated horse and uses minimally invasive incisions and minimal soft tissue dissection compared to the open subtotal ostectomy techniques.²⁵ The author has modified this technique to include removing a small portion of the cranial ODSP after transecting the interspinous ligament in cases where there is severe bony proliferation.

Evaluation after blocking may be difficult if behavior is intermittent. Some horses may have learned behaviors due to pain aversion that may persist for a time after blocking. In 2006, a paper by Roethlisberger demonstrated that blocking the interspinous ligament in normal horses increased ROM and dorsoventroflexion.

PROGNOSIS

It can be very difficult to interpret the actual prognosis of various treatments because the diagnosis of ODSP varies among the studies as does the definition of success. The presence of concurrent lameness obviously also affects long term prognosis for performance. Most of the studies listed below attempted to exclude horses with concurrent lameness.

• Medical Treatments

■ Retrospective studies evaluating individual conservative or medical treatments are lacking. In a retrospective study comparing medical treatment vs. interspinous desmotoy by Coomer et al. (2012), 89% of 34 horses improved significantly after injection with methylprednisoolone adjacent to the ODSPs but many had recurrent back pain, so the long-term success rate was only 42%.²⁰

• Subtotal or Cranial Ostectomy of the DSP

■ In a retrospective study by Walmsley et al. (2002), 215 horses had partial ostectomy of the DSPs under general anesthesia. The diagnosis was made based on history and clinical signs of back pain, radiographic changes of ODSP and positive response to infiltration of local anesthetic at the ODSP sites. 81% returned to work following surgery and 72% returned to full work.

■ A study by Brink et al. (2014) evaluated 24 horses with ODSP that had standing subtotal ostectomies of ODSPs. Horses were included in the study if they had

Image courtesy of Dr. Aric Adams.

impaired athletic performance caused by ODSP, radiographic changes associated with ODSP, improved with local anesthetic near the ODSP, and failed medical management. At less than one year, 86% returned to full athletic function and 77% had full athletic function at greater than one year.

■ Jacklin et al. published a retrospective study in 2014 that evaluated a cranial wedge ostectomy of the DSP in 25 horses found to have ODSP. 19 horses were available for long term follow-up of which 15 horses (79%) had complete resolution of clinical signs and were in full work. Three horses were improved and working at a lower level.

■ In a retrospective study, de Souza et al. (2022) evaluated a minimally invasive technique performing a cranial ostectomy in 102 standing horses. Horses were included in the study if they had clinical signs of back pain, radiographic ODSP, and either responded to diagnostic analgesia or had a positive bone scan or improved after injecting the ODSP with corticosteroids.

This study split horses into two groups: those with concurrent lameness issues and those without concurrent lameness issues. Of the 74 horses available for long term follow-up, eight horses had been euthanized (two due to persistent back pain, others due to lameness etc.).

Ȇ 69% of the remaining horses treated with the ostectomy for ODSP that had concurrent lameness returned to the same or higher level of work.

Ȇ 93% of remaining horses treated that did not have concurrent lameness returned to the same or higher level of work.

• Interspinous Ligament Desmotomy (ISLD)

■ In a retrospective paper by Coomer et al. (2012), horses were identified with ODSP with marked signs of back pain by history and physical exam, had no evidence of lameness, and had radiographic ODSP. 95% of 35 horses treated with ISLD had alleviation of clinical signs attributable to back pain and 82% had returned to normal function long term.

Preoperative (A) and three-years postoperative (B) lateral-lateral radiographs of a horse that had resection of four sites of overriding dorsal spinous processes and has returned to full athletic function. Radiographs were obtained for clinician interest. Image courtesy of Dr. Aric Adams.

■ A study by Prisk et al. (2019),w found that 51 of 56 horses with long term follow-up (median 35 months) returned to some level of work. Of these horses, a lower level of performance was noted in 24 of 51 horses, with 37.5% being from recurrent back pain, 37.5% being from unassociated lameness, and 25% from owners that decided to reduce the horse’s level of riding. The initial diagnosis of ODSP was made based on clinical signs of back pain, radiographic ODSP, and nuclear scintigraphy in 45% of the horses. Radiographic and scintigraphic grades did not impact return to performance.

■ Brown et al. found that nine out of 10 horses that had their ODSPs blocked prior to surgery were improved postoperatively, compared to only four out of eight horses that were not blocked prior to surgery.

■ A retrospective study by Derham et al. compared 159 racing Thoroughbreds with matched cohorts and found that they had improved racing performance. Eight horses developed unilateral neurogenic atrophy of epaxial musculature.²⁶

Pain from ODSP in horses can be difficult to discern from other sources of back pain. Behavior and poor performance that are often linked to ODSP are also commonly associated with a variety of problems including some that are entirely behavioral. It is of the utmost importance to be thorough in your examination to rule out other sources of pain or lameness and not rely entirely on the radiographic presence of ODSP when making a diagnosis. Nuclear scintigraphy and response

to diagnostic analgesia are useful in confirming ODSP. There are many effective treatments in managing ODSP in horses. Conservative and medical management is effective in treating many horses, but there is minimal scientific data to help guide us in regard to prognosis. When medical intervention fails, surgical treatments appear to give longer resolution to pain associated with this condition. In general, the overall prognosis for most surgical interventions is around 80%, and there are few complications associated with the surgeries that are used.

REFERENCES

1. Djernaes JD, Nielsen JV, Berg LC. Effects of x-ray beam angle and geometric distortion on width of equine thoracolumbar interspinous spaces using radiography and computed tomography- a cadaveric study. Vet Radiol Ultrasound. 2017 Mar;58(2):169-175.

2. Greve L, Dyson S. Saddle fit and management: An investigation of the association with equine thoracolumbar asymmetries, horse and rider health. Equine Vet J. 2015 Jul;47(4):415-21.

3. Girodroux M, Dyson S, Murray R. Osteoarthritis of the thoracolumbar synovial intervertebral articulations: clinical and radiographic features in 77 horses with poor performance and back pain. Equine Vet J. 2009 Feb;41(2):130-8.

4. García-López JM. Neck, Back, and Pelvic Pain in Sport Horses. Vet Clin North Am Equine Pract. 2018 Aug;34(2):235-251

5. Mayaki AM, Abdul Razak IS, Adzahan NM, et al. Clinical assessment and grading of back pain in horses. J Vet Sci. 2020 Nov;21(6):e82.

6. Brown KA, Davidson EJ, Ortved K, et al. Long-term outcome and effect of diagnostic analgesia in horses undergoing interspinous ligament desmotomy for overriding dorsal spinous processes. Vet Surg. 2020 Apr;49(3):590-599.

7. Roethlisberger Holm K, J Wennerstrand, U Lagerquist, et al. Effect of local analgesia on movement of the equine back. Equine Vet . 2006 Jan;38(1):65-9.

8. de Souza TC, Crowe OM, Bowles D, et al. Minimally invasive cranial ostectomy for the treatment of impinging dorsal spinous processes in 102 standing horses. Vet Surg. 2022 Jul;51 Suppl 1:O60-O68.

Horses may exhibit a girthy appearance and bite or act resentful during saddling.

9. Zimmerman M, Dyson S, Murray M. Close, impinging and overriding spinous processes in the thoracolumbar spine: the relationship between radiological and scintigraphic findings and clinical signs. Equine Vet J. 2012 Mar;44(2):178-84.

Image courtesy of Dr. Aric Adams.

10. Sayers E, Tabor G. An exploration of clinical reasoning and practices used by physiotherapists in the rehabilitation of horses following interspinous ligament desmotomy surgery. Physiother Theory Pract. 2022 Jul;38(7):897-907.

11. O'Sullivan S, McGowan CM, Junnila J, et al. The effect of manually facilitated flexion of the thoracic spine on the interspinous space among horses with impinging dorsal spinous processes of the thoracic vertebrae. Vet J. 2022 Sep 29;289:105909.

12. Pigé C, Masseau I, Bonilla AG. Influence of abdominal elevation on radiographic measurements of the thoracolumbar interspinous spaces in asymptomatic horses. Can Vet J. 2020. Oct;61(10):1101-1105.

13. Trager LR, Funk RA, Clapp KS, et al. Extracorporeal shockwave therapy raises mechanical nociceptive threshold in horses with thoracolumbar pain. Equine Vet J. 2020 Mar;52(2):250-257.

14. Johnson SJ, Richards RB, Frisbie DD, et al. Equine shock wave therapy - where are we now? Equine Vet J. 2022 Oct 9. 1-14

15. Xie H , Colahan P, Ott EA. Evaluation of electroacupuncture treatment of horses with signs of chronic thoracolumbar pain. J Am Vet Med Assoc. 2005 Jul 15;227(2):281-6

16. Haussler K, Holt TN. Spinal Mobilization and Manipulation in Horses. Vet Clin North Am Equine Pract. 2022 Dec;38(3):509-523

17. Sullivan K, Hill A, and Haussler K. The effects of chiropractic, massage, and phenylbutazone on spinal mechanical nociceptive thresholds horses without clinical signs. Equine Vet J. 2008. 40. P14-20

18. https://magnawavepemf.com/faq/

19. Roberts EJ. Resection of thoracic or lumbar spinous processes for relief of pain responsible for lameness and some other locomotor disorders of horses. Proc Am Assoc Equine Practnrs 1968;14:13-30

20. Coomer RPC, McKane SA, Smith N, et al. A controlled study evaluating a novel surgical treatment for kissing spines in standing sedated horses. Vet Surg. 2012 Oct;41(7):890-7

21. Walmsley JP, Pettersson H, Winberg F, McEvoy F. Impingement of the dorsal spinous processes in two hundred and fifteen horses: case selection, surgical technique and results. Equine Vet J. 2002 Jan;34(1):23-8.

22. Brink P. Subtotal ostectomy of impinging dorsal spinous processes in 23 standing horses. Vet Surg. 2014 Jan;43(1):95-8.

23. Jacklin BD, Minshall GJ, Wright IM. A new technique for subtotal (cranial wedge) ostectomy in the treatment of impinging/overriding spinous processes: Description of technique and outcome of 25 cases. Equine Vet J. 2014 May;46(3):339-44.

24.Vandeweerd JM, Desbrosse F, Clegg P, et al. Innervation and nerve injections of the lumbar spine of the horse: a cadaveric study. Equine Vet J. 2007 Jan;39(1):59-63.

25. Prisk AJ, García-López JM. Long-term prognosis for return to athletic function after interspinous ligament desmotomy for treatment of impinging and overriding dorsal spinous processes in horses: 71 cases (2012-2017). Vet Surg. 2019 Oct;48(7):1278-1286

26. Derham AM, O’Leary JM, Connolly SE, et al. Performance comparison of 159 Thoroughbred racehorses and matched cohorts before and after desmotomy of the interspinous ligament. Vet J. 2019 Jul;249:16-2

27. Merrifield-Jones M, Tabor G, Williams J. Inter- and IntraRater Reliability of Soft Tissue Palpation Scoring in the Equine Thoracic Epaxial Region. J Equine Vet Sci. 2019 Dec;83:102812.

Aric Adams, DVM, DACVS

Dr. Aric Adams was a farrier for eight years while obtaining his undergraduate and veterinary degrees. After graduating from the University of MissouriColumbia with a DVM, he completed an internship at an equine hospital in Colorado. Dr. Adams then practiced for one year at an equine hospital in Utah before moving to Florida to begin his surgical training. He completed his surgical residency at the University of Florida in 2005. After working in Tallahassee and Brandon as an associate equine surgeon, Dr. Adams joined the Equine Medical Center of Ocala in 2006. His caseload is primarily made up of lameness, diagnostics, and general surgery, including soft tissue and orthopedic surgeries.

Practice Management

CREATIVE SOLUTIONS FOR KEEPING Equine Veterinarians Off the Endangered Species Lists

Martha Mallicote | DVM, MBA, DACVIM UF College of Veterinary Medicine

Retention of equine veterinarians in practice is a substantial challenge to our industry. We will examine the data on retention and detail the available evidence behind the loss of equine vets to other types of veterinary practice. There are examples of creative ways to address the most commonly cited challenges – let’s review how to incorporate them into practice.

INTRODUCTION

There is no denying that the equine veterinary profession is at an inflection point and creative solutions will be required to ensure that veterinary care continues to be available to horses across the U.S. The AAEP has taken this concern seriously and established efforts to both better recognize the causes for practitioners leaving equine practice and identify solutions that can improve interest and retention. As this work continues, we can start to apply the findings of their research to individual practices in need.

As a starting point, some of the issues reported by newer DVMs in equine practices include lack of mentorship, on-call schedules that leave no time for family and personal interests, lack of adequate support staff, struggles with setting boundaries, feelings of isolation, sexism or a “Boys Club” environment, low income, and pressure from employers not to take time off.

Practice owners also report multiple challenges, including difficulty hiring and retaining DVMs, fear of raising prices, struggles with staff communication, reluctance to set boundaries with clients, high accounts receivable and poor collection processes, difficulty paying attractive new graduate salaries, and struggles to establish shared on-call,

and competition from lay practitioners. The concerns of both practice owners and newer associate DVMs are all legitimate. The resolution of retention and practice success issues will require addressing most or all of these concerns.

SOLUTIONS

As a starting point, it is important for existing and long-standing practices to examine their culture. DVMs leaving equine practice have reported that some practices are not supportive

of their need for a life beyond work and have expectations of excessive workload since “that’s the way we’ve always done it.” Many experienced equine doctors were trained and have worked in environments that expected a 24/7 devotion to the practice – this is not a healthy approach to work and younger practitioners recognize that fact. More experienced doctors can themselves benefit from the perspective brought to practice by newer DVM graduates and use this perspective to improve the quality of practice life for all staff.

Develop a practice identity in lieu of individual doctors bonding with clients. This allows easier interchange between doctors if clients don’t expect to always see the same practitioner. This requires efforts from the reception and phone staff, doctors, and technicians to institute a culture where clients can expect to receive the same excellent care regardless of what doctor is coming to their farm. When more senior doctors and long-standing office staff voice strong support for the “new docs,” then clients will more easily accept the new face. Doctors are more easily able to protect their time and take appropriate time away from practice when clients are happy to see another doctor in their absence.

Identify ways to reduce the on-call burden for doctors. Constant on-call stress and burnout is among the most substantial reasons for equine doctors to leave practice. The old model of the single doctor being available for their client on a 24/7 basis is no longer acceptable and likely contributes to poor mental health outcomes for our colleagues. For group practices, this can consist of true equal sharing of the on-call duties and ensuring that we support one another in allowing time off to be truly “off.”

In single or two-doctor practices, reducing on-call time requires more creativity and collaboration, but is still very possible to achieve. Sharing on-call responsibilities with area practices can be an extremely rewarding solution that balances the need to maintain a solo practice identity while also working together to support each other’s emergency needs. A truly collaborative approach is required for this type of arrangement to succeed – making sure that communication between all doctors is routine and open helps to prevent problems from becoming insurmountable challenges. Establish clear expectations at the outset about what calls will be seen (what constitutes a “current client”), how follow-up will be provided and how the primary doctor will be updated on the case. Concerns about losing clients to a colleague after they care for your client in an emergency are a small issue compared to the value gained from truly being “off-call” as a solo doctor – the time off is worth far more than a couple of clients that might shift primary doctors amongst the group.

Also consider the use of locum veterinarians (or technicians!) when coverage is needed for family/medical leave and longer vacations. This will support the staff that are not on leave and ensure that everyone maintains their healthy balance even in times of temporary staff shortages. Maintaining positive relationships with colleagues that leave your practice or another local practice may help them become ideal sources of locum

Image courtesy of Canva.

Image courtesy of Canva.

assistance in the future. Resources are also available from the AAEP and several private staffing companies that focus on locum veterinarians. As we increase demand for locum equine veterinarians, the market will respond by providing additional resources in that area.

The model of emergency-focused doctors or practices is also a novel solution that has been successful. These practices or solo doctors focus only on providing emergency care in after-hours windows. By establishing strong relationships with “referring DVMs” who know that the clients will be returned to them for follow-up and routine care, this business model can both fill a need for the local veterinary practices and allow for unique working schedules that may appeal to doctors in need of non-traditional work hours for family or other reasons. It is important to structure these models with compensation for the emergency veterinarian that is not solely dependent on caseload in order to retain them in the position long-term.

and lax/delayed billing practices that encourage missed charges. All these practices will reduce business income generation and decrease available funds to support salary and wage increases. Establish and update financial policies to require payment at time of service and communicate this clearly to clients in advance of care being provided. Technology available for use on the road has made the process of billing and collection at each appointment much easier and quicker than in the past. Additionally, charging a fair and adequate amount for time spent by practitioners on care and patient assessment will also generate funds that support employees. Over the long run, appropriate and adequate revenue generation will sustain equine veterinary salaries and practices into the future.

There is no single or quick solution to the issues of attraction and retention of veterinarians in equine practice. As a professional group, we will need to consider creative and novel solutions as well as learn to adjust our own expectations about practice life in ways that will also benefit existing practitioners. We will all likely have improved practice trajectories by implementing needed changes in work and career expectations for equine veterinarians.

Encourage doctors and staff to establish boundaries around their personal time. Clients have come to expect their doctors to be available to them 24/7 via personal phones. While excellent client service is important, we can also train clients about what is an emergency concern and what is not. Using telemedicine (and charging for it!) can allow us to provide that level of availability that some clients desire while also being compensated for the associated time. Further, fostering a “practice identity” instead of individual doctor-client bonds (as discussed above) also serves the purpose of shifting emergency needs onto the on-call doc instead of spreading them out among all doctors. Establish communication methods that run through the practice instead of directly to each doctor, making it harder for clients to reach doctors that are off duty.

Finally, practice financial policies may need adjustment to also support strong practice profitability and allow for fair and competitive compensation for all staff. Equine veterinarians are notorious for allowing large accounts receivable balances

Martha Mallicote completed her undergraduate work at the College of Charleston in South Carolina, completed a master of business administration degree at the University of Florida, and is a 2006 graduate of the University of Tennessee College of Veterinary

Medicine. Since graduation, she has worked in both ambulatory and referral hospital settings, including an internal medicine fellowship at Rood and Riddle Equine Hospital. In 2012, Dr. Mallicote completed her residency in large animal internal medicine at the University of Florida and joined the faculty. She was appointed to the Weeks Endowed Professorship in Veterinary Medicine in 2018 by colleagues at the University of Florida. Her professional interests include endocrinology, neonatology, and veterinary business management.

Martha Mallicote, DVM, MBA, DACVIM

Image courtesy of Canva.

Professional Development

MENTORSHIP IN Veterinary Medicine

Jillian Sinclair | Marketing Specialist Florida

Veterinary Medical Association

One of the most important parts of building a career in veterinary medicine is having a mentor to guide you through the experience. A mentor influences the personal and professional growth of their mentee and plays a huge role in their success. Mentorship can provide many benefits for both mentors and mentees. Developing a strong relationship allows both of you to learn, network, and grow as professionals.

It’s common for mentorships to start during veterinary school because students seek guidance from professors, through internships, or in the veterinary community. Dr. Martha Mallicote, an associate professor at the University of Florida College of Veterinary Medicine (UFCVM), is very involved in her students' growth and has become a mentor to many of them. She says a mentor is a unique role that is different from a supervisor or boss.

“A mentor is someone that will both advocate for the mentee and have hard discussions with them about their skills and weaknesses,” says Dr. Mallicote. “They play an important role in helping a mentee plan a career path, make choices that support that career path, and achieve happiness in their ultimate professional role.”

MENTORING A STUDENT

Dr. Mallicote says one of her favorite parts about her current role at the University of Florida is working with students and coaching them as they complete veterinary school. As a mentor, she helps prepare students for their clinical careers and what they will face after graduating.

According to Dr. Mallicote, “An effective mentor listens more than they talk. They help the mentee figure out the needed solution, as opposed to dictating it.” Allowing the student to think through the issue and find the solution with their mentor's guidance is one of the best ways to instill confidence in the mentee. This will teach them how to find the solution, without simply handing them the answer. Mentoring students this way is a great way to prepare them for working on their own without throwing them into the deep end too soon.

Image courtesy of the Florida Veterinary Medical Association.

Another tip Dr. Mallicote has for student mentors is to start with a clear plan. She suggests talking with students about their mentorship needs and planning how often they need to meet in order to achieve their goals.

“A good mentor is committed to regularly meeting with their mentee and providing focused attention to the mentee’s concerns and questions.” Dr. Mallicote says that it’s easy to put talks like this on the back burner, so it is best to set up a course of action from the beginning to ensure both parties understand the goals and needs of each other.

“It's important to discuss exactly what a successful mentormentee relationship looks like to both parties. That includes both the time commitment expectations and what intensity of support will be offered,” says Dr. Mallicote.

ADVICE FOR A STUDENT MENTEE

As a student, finding the right mentor can be a daunting task. Students are quickly introduced to many professors and leaders who might all seem like good mentors. Before moving forward, Dr. Mallicote says it is crucial to discuss what a successful mentormentee relationship looks like to both parties. She suggests students talk about their goals and the intensity of support the mentor is willing to offer. Similar to a mentor asking the student what kind of time commitment they are looking for, a student should always ask the potential mentor what amount of time they are willing and able to give to the mentorship. Some veterinarians might want to meet daily, weekly, or even monthly depending on the type of mentorship.

Students need to think about how much interaction they are going to want with their mentor before starting the mentorship. If they expect daily conversations with a mentor and they are only able to meet with them once a week, both will be disappointed in the relationship. It’s necessary to be on the same page so both parties know exactly how much they can expect. This also allows students to be respectful of their mentor’s time.

It’s important to remember that mentors are usually established, working veterinarians and professionals who have many responsibilities other than mentorship, and students should always be respectful and courteous of the time they are being offered.

MENTORING A RECENT GRADUATE

Now FVMA President and former FAEP President, Dr. Jacqueline Shellow has been practicing veterinary medicine for over 35 years. Throughout her career, she has been a mentee and a mentor to many veterinarians.

Dr. Shellow says that one of the most important things an established veterinarian can do for mentees is to give back by sharing their knowledge and experiences while helping them grow professionally.

“Help someone gain as much experience and confidence as you can give them through yours,” she says. Sharing your knowledge and practical experience will help prepare mentees for a long-term career in veterinary medicine.

Dr. Taylor McLendon graduated from UFCVM in 2019. As an experienced mentee and mentor, she says, “As a mentor, never forget that you are shaping the mind of the future of our profession. It can be so easy to focus on the negative and point out all of the downfalls and shortcomings of being a veterinarian, but we have to focus on the positive. If you discuss a shortcoming, focus on solutions and discuss a path towards improvement.”

The support you give to your mentee at the beginning of their career will affect the way they grow as a veterinarian. Being able to guide them through hardships and mistakes will help them become independent and confident enough to succeed in the profession.

Image courtesy of the Florida Veterinary Medical Association.

Image courtesy of the Florida Veterinary Medical Association.

ADVICE FOR RECENT GRADUATES

As a recent graduate, Dr. McLendon knew she needed a veterinary mentor, but also wanted to learn more about business ownership. She knew that owning her own practice was one of her career goals and wanted to gain experience from someone who would be able to show her the ropes of running a veterinary practice as a business.

“There are so many things that we learn throughout our curriculum,” Dr. McLendon says. “However, nothing can compare to experience. The one-on-one relationship between a mentor and mentee cannot be captured in a textbook. Learning from the experience of a mentor is invaluable.”

She recommends finding a mentor who exemplifies a similar lifestyle to what the mentee would like to achieve in their personal and professional life. For example, if their goal is to be a working mom, seeking out a working mom as a mentor can teach them how to successfully accomplish that goal. Finding a mentor who is successfully doing what the mentee wants to accomplish in the future is one of the best ways to learn what they need to be doing in their career.

Dr. McLendon also suggests abiding by the “actions speak louder than words” saying. She recommends paying attention to the day-to-day actions of mentors. A young veterinarian will probably know the correct answer to a problem, but being able to walk through the solution with the guidance of an experienced veterinarian is an invaluable opportunity.

MENTORING IN EQUINE VETERINARY MEDICINE

The American Veterinary Medical Association’s (AVMA) 2022 State of Profession Report shared data that highlights how equine veterinarians are struggling.

• 1.4% of new graduates work in equine practice.

• 16% of internship positions were in the equine sector.

• The average companion animal-exclusive practice salary is $103,881. Equine practitioners' average salary is $54,539.

• Only 6.8% of practice owners are equine specific.

• Equine practitioners work the most hours of all vets with an average of 54.3 per week.

• 49% of equine practitioners have considered leaving the veterinary profession.

While mentorship is important in all veterinary sectors, it is especially needed for equine practitioners today. Dr. Mallicote feels that equine practice has to change in order to improve the retention of veterinarians.

“These changes require a change in culture that we are starting to see in action,” she says. “Mentors can help support these changes by demonstrating to newer practitioners another way to practice equine medicine – one that does not require a 24/7 devotion to the practice at the expense of personal life and health.” Sharing ways to effectively practice equine medicine while keeping an appropriate work/life balance will allow equine practitioners to thrive in both their work and personal life.

Dr. McLendon also believes that helping equine veterinarians achieve a healthy work/life balance will play a big role in bettering the profession. “Equine veterinarians are stereotypically hardworking, suck-it-up, grit-your-teeth kind of people,” she says. “As a mentor, I try to remind my students that it is okay to take a break sometimes and focus on yourself.” She suggests trying to do one thing a day that makes you happy, but that is not related to veterinary medicine as it’s important to take personal time away from your job and focus on your personal life. “This is something that needs to be seen and not taught," she says. “Mentorship is essential to decreasing the work hours of the equine veterinarian.”

Overall, effective mentorship for equine veterinarians is needed to improve the state of the profession. In reference to 49% of equine veterinarians considering leaving the profession, Dr. McLendon says she feels it is because of how the profession has been portrayed for so long. “Younger graduates see retirement age veterinarians still working 50-60-hour weeks, working weekends, and seeing late-night emergencies.” She continues, “If we can change the narrative [through mentorship], we can retain more practitioners.”

Image courtesy of the Florida Veterinary Medical Association.

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Dentistry

EQUINE DENTISTRY IN THE STATE OF FLORIDA:

Educating Clients on the Legal Medical Aspects Surrounding Equine Dentistry

Katherine Pearce | Senior Creative Lead Florida Veterinary Medical Association

According to the 2022 Florida Statutes, veterinary medicine in the state of Florida includes, with respect to animals, surgery, acupuncture, obstetrics, dentistry, physical therapy, radiology, theriogenology, and other branches or specialties of veterinary medicine.1

While dentistry is legally considered under the umbrella of veterinary medicine, the ‘floating’ of equine teeth falls into a particular gray area. Although the definition of the term “practice of veterinary medicine” in Florida includes dentistry, the manual hand floating of teeth in equines by non-veterinarians is something that has existed in Florida for many years and is considered to be legally acceptable. Florida is one of only 19 states that exempt equine teeth floating from the practice of veterinary medicine, thereby allowing nonveterinarians to perform the task without supervision by a veterinarian. The majority of U.S. states mandate that licensed veterinarians are solely able to perform equine dental treatments and procedures.² Those states that exempt floating (including Florida) only allow it under certain specific conditions, such as only being performed with manual tools.

“EQUINE DENTISTS”

As mentioned above, a veterinarian refers to a person who is licensed to engage in surgery, acupuncture, obstetrics, dentistry, physical therapy, radiology, theriogenology, and other branches or specialties of animal medicine.

A veterinary technician (CVT) instructs clients, performs laboratory testing, takes radiographs, provides skilled nursing care to animal patients, administers medications, and assists in anesthesia and surgery. These tasks are done at the direction of a veterinarian but may be performed with varying levels

of supervision as specified by the Veterinary Practice Act.³ Technicians, as outlined below, represent the only exception to utilizing sedation in equine teeth floating.

Prior to 2006, Florida law stated the following:

(5)(a) Any person, or the person’s regular employee, administering to the ills or injuries of her or his own animals, including, but not limited to, castration, spaying, and dehorning of herd animals, unless title is transferred or employment provided for the purpose of circumventing this law¹, This exemption does not apply to any person licensed as a veterinarian in another state or foreign jurisdiction and practicing temporarily in this state.

Image courtesy of Canva

However, only a veterinarian may immunize or treat an animal for diseases that are communicable to humans and that are of public health significance.

In 2006, the following language was enacted:

(b) A person hired on a part-time or temporary basis, or as an independent contractor, by an owner to assist with herd management and animal husbandry tasks for herd and flock animals, including castration, dehorning, parasite control, and debeaking, or a person hired on a part-time or temporary basis, or as an independent contractor, by an owner to provide farriery and manual hand floating of teeth on equines. This exemption does not apply to any person who has been convicted of a violation of chapter 828 that relates to animal cruelty or a similar offense in another jurisdiction.

Rule 61G18-17.005, F.A.C., is the rule that lists the tasks that require the immediate supervision by a veterinarian. Immediate supervision is on-premises supervision, whereas general supervision is off-premises. Paragraph (1)(a) of that rule allows a veterinary technician to administer treatment, as directed by the veterinarian, under general supervision. Paragraph (2) of that rule states that the administration of anesthesia or tranquilization by a veterinary technician requires immediate supervision. These paragraphs indicate that a veterinary technician could use motorized tools to float teeth under general supervision, but only if anesthesia or tranquilization is not required.

While veterinarians and veterinary technicians have defined roles, abilities, education, and licensing or credentialing bodies they must answer to, an ‘equine dentist’ is a layman who has no such education or credentialing. The titles ‘equine dentist’ or ‘dental specialist’ do not refer to an equine veterinarian capable of providing comprehensive care.

It is key that your clients understand the limitations of layman ‘equine dentists,’ both legally and practically – and why it is, therefore, key to utilize and consult their equine veterinarian in all matters relating to their horse’s health, including dental needs, as there are many conditions which a non-veterinarian dentist cannot address or fix. Aside from the above exception for veterinary technicians, it is not legal for a non-veterinarian layman ‘equine dentist’ or ‘equine dental specialist’ to sedate a horse, perform extractions or do other dental procedures, including those utilizing power tools. These limitations greatly affect the dental care being provided to clients’ horses, and clients should be made aware of this to ensure that their horse’s mouth is adequately cared for rather than solely relying on a ‘equine dentist.’

It is worth noting that the language these ‘specialists’ use can be confusing for clients. Although there is a board certification process for veterinary dental medicine, there is currently no specific “equine only” tract for this specialty. Should a veterinarian wish to become board-certified in dentistry, they would be required to learn and study all species (including equine) as they pertain to dentistry. State veterinary bodies are responsible for the process of licensing and to a certain extent enforcing the laws as they pertain to veterinary medicine.⁴

‘Equine dentists’ or ‘equine dental specialists’ may have any degree of training and are not held up to veterinary licensing standards. As veterinary laws and rules can only be enforced on licensed veterinarians, treatments done by laypersons are open to unusual liabilities. Horse owners have little or no recourse if there are issues with the work performed by the lay person. On the other hand, if a lay person is working under the supervision of a licensed veterinarian, then that lay person is acting as a veterinary technician, and the veterinarian is responsible for the acts performed by a veterinary technician under her or his supervision.⁴

Image courtesy of Canva

Image courtesy of Canva

DEALING WITH CLIENTS

If the lack of legal recourse is not enough to deter clients, inadequate care, pain, and potentially permanent damage to their equine’s mouth should also be noted. An equine’s mouth is highly evolved and complex. Its job, diet, genetics, age, and other factors affect the type and frequency of dental work that may be required. Dental procedures, even routine ones, can lead to complications and even injuries, such as fractured or loosened teeth due to chewing on floats or worse.⁴ A licensed veterinarian, unlike a layperson, is highly qualified to provide care, diagnose, and offer a more wholistic view of an equine’s health. If you do not provide comprehensive equine dental care, you can refer your clients to a veterinary colleague that does.⁴

IN CONCLUSION

When speaking with clients, it is key they understand the scope of care that can be provided by an ‘equine dentist’ versus a licensed veterinarian. While you may not change their mind if they are committed to using a layman dentist, you will have

ensured they are caring for their equines with full knowledge, and they will at least have a thorough understanding of what the limitations and consequences may be. It is also worth reminding clients that if they are traveling with their horses in one of the 31 states which does not exempt equine teeth floating from the practice of veterinary medicine, they will need to seek out a licensed veterinarian if their horse needs dental care.

REFERENCES

1. http://www.leg.state.fl.us/statutes/index.cfm?App_ mode=Display_Statute&URL=0400-0499/0474/0474. html

2. https://www.avma.org/advocacy/state-local-issues/authorityveterinary-technicians-and-other-non-veterinariansperform-dental-procedures

3. https://equimed.com/health-centers/dental-care/articles/ equine-dentist-laws-by-state

4. https://aaep.org/issue/equine-dental-care-what-every-horseowner-should-know

THE AAEP'S POSITION ON EQUINE DENTISTRY

The practice of equine dentistry is an integral branch of professional equine veterinary practice. This discipline encompasses all aspects of the evaluation, diagnosis, prognosis, treatment, and prevention of any and all diseases, disorders, and conditions that affect the teeth, oral cavity, mandible, maxillofacial area, and the adjacent and associated structures. Additionally, equine dentistry includes the evaluation of the presentation and contribution of systemic diseases within the oral cavity and the contribution of oral conditions to the overall health of the individual horse.

Any surgical procedure of the head or oral cavity; the administration or prescription of sedatives, tranquilizers, analgesics or anesthetics; procedures which are invasive of the tissues of the oral cavity including, but not limited to, removal of sharp enamel points, treatment of malocclusions of premolars, molars, and incisors, odontoplasty, the extraction of first premolars and deciduous premolars and incisors; extraction of damaged or diseased teeth; treatment of diseased teeth via restorations or endodontic procedures; periodontal and orthodontic treatments; dental radiography and endoscopy of the oral cavity are veterinary dental procedures and should be performed by a licensed veterinarian.

In states where the Veterinary Practice Act allows, the AAEP supports the use of licensed veterinary technicians under the employ and immediate supervision of licensed veterinarians for specific and appropriate veterinary dental procedures as enumerated in that state’s practice act.

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Important Satefy Information

As with all drugs, side effects may occur. For intramuscular use in horses only. Not for use in humans. Pentosan polysulfate sodium is a weak anticoagulant. Caution should be used when administering Zycosan if you are taking an anticoagulant. In case of accidental self-injection, seek immediate medical attention. If product comes into contact with skin, rinse skin thoroughly with water and seek medical attention if needed. Horses with hypersensitivity to pentosan polysulfate sodium should not receive Zycosan. Do not use Zycosan concurrently with other anticoagulant drugs. Do not use in horses with clotting disorders or within 24 hours of surgical procedures. Caution should be used when administering this drug before or after strenuous activities. Caution should be used when NSAIDS are administered concurrently due to the anticoagulant effects of Zycosan. If Zycosan and NSAIDS are used concurrently, horses should be monitored for hemorrhage or other clinical signs of abnormal bleeding. The safe use of Zycosan has not been evaluated in breeding, pregnant, or lactating horses. The safety of long-term repeat use of Zycosan has not been evaluated. The most frequently reported adverse reactions are injection site reactions, prolongation of coagulation parameters (activated partial thromboplastin time (aPTT) and prothrombin time (PT). Refer to the prescribing information for complete details or visit www.dechra-us.com.

Zycosan®

(pentosan polysulfate sodium injection)

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For intramuscular use in horses only.

Brief Summary (For Full Prescribing Information, see package insert)

CAUTION: Federal law restricts this drug to use by or on the order of a licensed veterinarian.

DESCRIPTION: Zycosan contains pentosan polysulfate sodium, a semisynthetic polysulfated xylan.

It is a pale yellow to brownish yellow, clear, sterile solution.

INDICATION: For the control of clinical signs associated with osteoarthritis in horses.

CONTRAINDICATIONS: Horses with hypersensitivity to pentosan polysulfate sodium or any of the inactive ingredients in Zycosan should not receive Zycosan. Do not use Zycosan concurrently with other anticoagulant drugs. Do not use in horses with clotting disorders or within 24 hours of surgical procedures (see Warnings and Precautions).

WARNINGS AND PRECAUTIONS:

User Safety Warnings: Not for use in humans. Keep out of reach of children. Pentosan polysulfate sodium is a weak anticoagulant. Caution should be used when administering Zycosan if you are taking an anticoagulant. In case of accidental self-injection, seek immediate medical attention. If product comes into contact with skin, rinse skin thoroughly with water and seek medical attention if needed. To obtain a Safety Data Sheet (SDS), contact Dechra at (866) 933-2472.

Animal Safety Warnings and Precautions:

Zycosan has been shown to prolong coagulation parameters up to 24 hours after injection, therefore caution should be used when administering this drug before or after strenuous activities (see Target Animal Safety). Due to the anticoagulant effects, this drug may exacerbate Exercise Induced Pulmonary Hemorrhage (EIPH).

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The concurrent use of NSAID with Zycosan has not been evaluated. Due to the anticoagulant effects of Zycosan and known anticoagulant effects of some NSAIDs, caution should be used if NSAIDs are concurrently administered. Horses concurrently treated with Zycosan and NSAIDs should be monitored for hemorrhage or other clinical signs of abnormal bleeding (e.g., petechiae, ecchymosis, or epistaxis). The safety of long-term repeat use of Zycosan has not been evaluated. Pigmentary changes in the retina (pigmentary maculopathy) have been reported in human patients following long-term oral use of pentosan polysulfate sodium. It is not known if a similar finding occurs in horses. The safe use of Zycosan has not been evaluated in breeding, pregnant, or lactating horses.

Other Warnings: Do not use in horses intended for human consumption.

ADVERSE REACTIONS:

Injection site reactions were the most frequently reported adverse reactions in the field study. Injection site reactions were associated with clinicopathology changes in some cases. Other adverse reactions reported in more than one horse were prolongation of coagulation parameters (activated partial thromboplastin time (aPTT) and prothrombin time (PT)), lethargy, behavior changes, and colic.

To report suspected adverse events, for technical assistance or to obtain a copy of the Safety Data Sheet (SDS), contact Dechra at (866) 933-2472 . For additional information about adverse drug experience reporting for animal drugs, contact FDA at 1-888-FDA-VETS or online at http://www.fda.gov/reportanimalae.

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